Accessebility to Psychiatric Services in Georgia

Background: Heavy socio-economic condition and military conflicts negatively affected mental health condition of the population in recent years in Georgia. Eventually, prevalence of mental disorders has increased. Despite the fact that allocation of funds for state program on mental health has been annually increasing, it is still quite low and amounts only 2,11% of the total expenses on health care (2012). Scarcity of resources is also preconditioned by low development of relatively cost-effective, out-of-hospital, community-based mental health services in the country. The purpose of survey is to study accessibility to mental health services in Georgia, to identify gaps existing in mental health state program. Methodology: Within the qualitative study the in-depth interviews were conducted among the managers of medical institutions and medical personnel. Face-to-face interviews using specially designed questionnaire were conducted among mental health state program beneficiaries as part of the quantitative research. Findings and discussion: under-funding of the mental health programs negatively affects patients' health. A large number of patients, who do not require inpatient psychiatric care, remain in psychiatric institutions due to lack of development of out-patient, community based mental health services; while many of those discharged from hospitals often return there because of re-hospitalization needs. The problem is further aggravated by the lack of professional personnel, unequal distribution of services throughout the country's territory, fewer outpatient psychiatric services development, and difficulties in ensuring the proper material-technical capacity, equipment and finances. Conclusion: For the development of mental health sphere it is necessary to elaborate effective funding mechanism, which will be tailored to the needs of patients; to enhance knowledge and skills of specialists in the field and their appropriate level of compensation; to facilitate the development of psychosocial rehabilitation centers, shelters and other services in the country; to expand the state programs over a non-psychiatric diagnosis and treatment; to change the public attitude towards the patients and to reduce stigma.


Preface
International human rights instruments impose obligation over the government towards persons with mental disabilities. Since 2007, new edition of the law of Georgia on "Mental health care" is in force which has greatly contributed to establishment of high standard of patients' rights, to develop recommendations for mental health policy; the inevitable need for de-institutionalization of mental health services has been conceived. It's on the agenda to create balanced and differentiated services at the level of first aid: social, community-based centers, general hospitals [1].

Psychiatric spread of disease
In Georgia in recent years, the heavy socio-economic situation and the military conflicts have negative affected mental health of the population. According to official statistics, since 1992 Georgia the prevalence of mental disorders has increased. In 2012, 78 296 people are registered mental or behavioral disorders, prevalence rate of inhabitants of 1743.5 per 100 thousand, 4075 new cases (incidence rate per 100,000 population -90.7), including children -183 (incidence rate -24.0). (NCDC. 2013).
Official statistical data about mental disorders is not precise and this number may be larger than the registered patients. According to experts, prevalence of mental disorders outnumbers the official data at least twice (Ministry of Health. 2010, p. 3). This is caused by the incomplete registration system and also, also the social stigma. Patients and their relatives avoid placement at the hospitals and often resort to self-treatment or apply not psychiatrists, but also physicians, neuropathologists and psychologists, who are less qualified in diagnosing these diseases and in some cases do not send the patient to a psychiatrist (the Ministry of Health. 2010, p. 31). For its part, the mental health program often cannot ensure their needs, due to which medical referral services is very low. The law on "psychiatric care", adopted in 1995 greatly contributed to this according to which patients were given the freedom to choose and the right to refuse to registration (Ministry of Health. 2010, p. 31).

Medical personnel
The mental healthcare system and delivered services essentially depend on the number and qualifications of the medical staff working in the network. In Georgia in 2000-2011 the number of psychiatrists decreased by 30%. In 2011, this figure was 1.6 per 1,000 people which is 0.7 points less than the minimum standard set by the World Health Organization's (at least 2.3 health workers per 1000 capita.) (NCDC. 2013. p. 51). Studies confirm that the level of knowledge and use of contemporary approaches, qualifications of professionals is not relevant; professional staff mainly consists of doctor-psychiatrists, psychologists and nurses; there are practically no social workers, occupational therapists, psychotherapists, community workers, family physicians (the Ministry of Health. 2010).

Infrastructure, bed fund
For many years, mental health services in the Georgia were characterized by a low quality, an redundancy of obsolete institutions, and inefficient infrastructure, with extreme low volume of the prevention, social integration and rehabilitation services (the Ministry of Health. 2010).
The main problem was the low development of outpatient services, leaving a large number of patients in psychiatric institutions not requiring inpatient psychiatric care, while discharged patients returning to the hospital soon after in need of re-hospitalization. In 2010, a new national program was developed for the hospital sector restructuring: "100 new hospitals", which provided: • The need for integrated services and the closure of the old psychiatric hospitals; • Treatment of acute psychiatric departments in multi-profile clinics; • Establishment of several long-term care homes (shelter).
In summer of 2011 the first phase of fundamental reform was planned, which intended to establish services in Tbilisi. In-patient service was divided into two: 1. Short-term inpatient services which implies relief of current condition of acute psychotic symptoms; 2. Long-term inpatient services which include continuation of treatment after short-term in-patient aid or treatment of patients who cannot be subject to in-patient treatment due to severe psycho-social functioning disorder.
Reform of general hospitals considers creation of a new infrastructure, in particular the establishment of an acute medical units, as well as the units for men and women (sections mixed character), which is a completely new concept of traditional psychiatry and did not exist in Georgia until now. Centers should be set up for patients with chronic mental diseases. In 2011 three hospital departments for adults and children were open (total 40 beds), as well as a research institute of acute and chronic patients, which merged several Neurological Dispensary; Crisis Intervention daycare Center with several beds and mobile groups was opened.
Working Group on reform proposed to create the so-called service of "Protected Living Environment" at Rustavi mental health center and a research institute. It considered medical services to the patients, who are homeless, or due to limited social skills cannot live independently, or family members avoid co-living with them. Because of this, they actually spend their lives in psychiatric hospitals and longterm care centers. At this stage it was impossible to introduce housing service and its development was postponed. It should be noted that the psychiatric centers were restored throughout the country. Repair works were carried out and in Kutaisi and Tbilisi and Batumi (Khelvachauri) long-term care units were opened, which were originally conceived as a residence places [1].

Financing
In the last decades the share of public spending in health care has significantly increased. Health care costs are increasing in parallel with the growth of the state budget expenditure for both outpatient and inpatient psychiatric services. In 2006-2012 years, the rate almost grew 2.4-times. Despite the growth, the expenses for mental health spending is 2,11% of the total healthcare spending. (Coalition of Mental Health, 2011). For comparison, the share of mental health expenditure in France is 5% of overall healthcare expenses, in the USA -6%, Australia -6.5%, Chile -4.1% (World Health Organization, 2012).
Mental health State program ensures the long-term mental health counseling, medical treatment, medicines. State Mental Health Program envisages funding of 840 GEL for emergency medical case and for chronic patients -450 Gel vouchers per month for hospitalization. The amount spent per patient per month in outpatient clinics (drugs, personnel, utility costs) on average is 10-15 GEL.
Mental health service under the state program is fully compensated by the state, except inpatient care of mental and behavioral disorders caused by psychoactive substances. In-patient care for mental and behavioral disorders caused by psychoactive substances is reimbursed by the state by 70%, except for alcohol intoxication, which is paid in full (SSA, 2014).

Methodology
The methodological basis of research is the review of problem in scientific papers concerning the mental health state programs, online editions, Center for Disease Control and Public Health Statistical Yearbook, National Reports.
The study included a qualitative component. The qualitative study was to identify problems related to mental health services. The qualitative component included in-depth interview with the representatives of mental health center and the parents of beneficiaries of the state healthcare program. The main study areas included: the financial access to mental health services, the hospital placement of the patients who do not require inpatient medical services, implementation and mental health state program, their vision in order to improve mental the state programs and the attitude of beneficiaries' parents towards the program. Qualitative study was carried out in April-May 2014, in-depth interview with the duration of approximately 2 hours.

Results and Interpretation
According to the representatives of medical institution, the number of patients with mental health problems is increasing annually; correspondingly, the state funding for mental health does not cover their needs. Due to lack of funding, less expensive and less new generation of medicines are used. The patients are given low cost older drugs not sufficient for the whole month, but only 15 days' supply. As a result, the patient is forced to buy the remaining days' supply of medications. This negatively affects the treatment outcomes. Poor treatment increases the frequency of exacerbations of the disease. According to experts, the financing scheme is not favorable neither for medical service providers nor for beneficiaries. After the state funding limit (single voucher for 840 GEL) for treatment of a patient with acute psychosis is used the medical institution tries to get rid of the patient, or the patient is transferred for the treatment of short and long term care that gives patient possibility for continuation of the treatment (Table 1).
There are cases when number of clinics avoids covering treatment expenses themselves and discharging a patient even with acute or nonstable psychotic condition. Also the amount allocated for outpatient care per patient is very low on average of 10-15 GEL per day (it includes all expenses: food, utilities, staff salaries, clothing, hygiene costs, etc.). Very scarce funding makes it practically impossible to provide the rehabilitation course. Obviously, in such a situation it is impossible to provide a full service and the patients cannot receive expensive rehabilitation course. Medical institution is forced to deliver only small scale rehabilitation course to patients (Figures 1-3).
Often, the medical institution has to bear the cost of treatment of a patient for the diseases which are not included in the state program. Treatment of Somatic and dental disease is a problem when a patient has a right to receive medical services other than psychiatric care. In opinion of the experts, the issue of re-hospitalization remains a pressing problem. When a patient discharged from the hospital returns there in 7 days, the case is considered as a re-hospitalization and the provider medical establishment doesn't receive any reimbursement. In this regard, the situation is complicated by the fact that the assessment of preliminary results for psychiatric treatment is not possible, and the patient discharged from the hospital cannot be under control, correspondingly, neither the medical institution can be held responsible for the patient's health condition. Due to the suspension of funding the hospital is forced to refuse to re-hospitalization of newly discharged patient. In such cases, often the hospital adheres to ethical principles and doesn't refuse the patient from re-hospitalization. As a result, the treatment is continued but without compensation to the hospital. In experts' opinion, one of the problems in acute cases is the difficulties in providing medical care. Current funding scheme is based on differentiation of the patients into acute and chronic ones which is not so simple in psychiatry and poses many problems for the proper functioning of the institution. Often no treatment is delivered unless the disease aggravates, which often poses difficulties to both patients and hospitals, since the psychiatric institution has to cover the costs of treatment. In addition, it is difficult to define the category of a patient -acute or chronic when awarding the status to a patient. Another problem is related to the tenders announced on the procurement of materials. According to experts, the hospital has to design a plan in advance for procurement during the year and submit it to the National Procurement Agency. Practically it is impossible to pre-define the volume of medicines which will be needed by the hospital during the year. Besides, the quality of drugs purchased under the tender are very low since as a rule the tender is won by a company proposing the lowest price. Eventually very often low quality medicines are provided with less therapeutic effect [2][3][4][5].
The existing funding scheme cannot cover the costs of quality services. Also, due to the scarcity of funding, the salaries of medical personnel are quite low, which cannot ensure attraction and maintenance of qualified personnel. In this regard, it is worth noting that there is a shortage of nurses, due to which the patient cannot get due attention; also, no continuing professional development is available, there is no systematic approach; no corresponding training for improvement of theoretical and practical clinical skills are in place. All the mentioned has a negative impact on the quality of medical services. According to experts, the financing through voucher system needs to be improved in order to be adjusted to the real needs. By their calculations, the optimal funding can be 20-25 GEL per patient per day in terms for the global budget; the additional funds should be allocated for the utility costs, material and technical maintenance, infrastructure development and construction. The conditions of persons with mental and behavioral disorder are considerably improved in comparison with previous years. It shall be mentioned that the part of the patients doesn't require treatment at the hospital. But for years they remain at the psychiatric hospital. This is partly caused by the patients not having the residence place. There are cases when the relatives refuse to take patient at home. For this purpose there is a service for chronic patients outside the hospital [5][6][7][8].
Patient's rights are often violated, in particular, their right to property. Patient's guardians, relative dispose their property without permission and uses for personal purposes, so after the recovery some patients have to live at the hospital, while a patient could return to own house. Strong negative stereotypes established in the society are reflected at the court's pre-disposition in support to healthy person rather than a patient. Users of the state program on psychiatry highlighted low level  that the patient or his relatives have no full information about the diagnosis, symptoms of diseases, course of treatment. Therefore, they cannot participate in the treatment processes. Also, the doctor is less interested in monitoring the treatment. As a result, the patient is forced to continue the treatment, which requires additional time and costs. In addition, the transportation of the patient to Tbilisi often aggravates patient's health condition [9][10][11][12][13][14].

Conclusion
Although the number of patients with mental health problems is annually increasing, the volume of funding for state mental health program does not increase. Due to the lack of funding the patients themselves have to cover the costs for certain services (e.g., Drugs), which negatively effects treatment outcomes. Often the medical institution itself is forced to bear the costs of the treatment. The problem of re-hospitalization still remains acute. The state program finances only urgent medical cases, which poses a challenge to both patients and hospitals. The funding does not cover the costs of quality services. Salaries of medical personnel are quite low. Part of the patients doesn't require hospital treatment, but because they do not have private property, remain at a psychiatric hospital for years. There is no outpatient medical service for chronic patients. The rights of patients are violated (including property rights). The court also supports the healthy plaintiff rather than a patient. The level of medical service in Tbilisi and the regions is not similar. Particularly, in regions the qualification of doctors is rather low. Awareness of the patients or their relatives about the course of treatment is low.
Based on the results of the research, the recommendations on mental health development were drafted, in particular, need to: • Sustainable, flexible and effective scheme of funding; • Provision of high-skilled specialists in the field and appropriate level of remuneration; • Supporting development of community-based services, such as psychosocial rehabilitation centers, shelters and other services throughout the country; • Increasingly state funding of non-psychiatric diagnosis and treatment; • Change of the attitudes of the society towards patients and reduce the stigma; • Based on consultations with stakeholder create a funding scheme, which will be tailored to the needs of patients and staff.